Remote Inpatient CDI RN II

BBSS Beyond Blue; Kentucky; Hybrid; USD 60,000 - 85,000; Full time

Job summary

University of Kentucky is seeking an Inpatient Clinical Documentation Specialist II to ensure accuracy, quality, and completeness of clinical documentation for patient care, regulatory compliance, and reimbursement. You will collaborate with providers, coders, case managers, and the healthcare team to validate severity of illness, risk of mortality, and medical necessity.

The role involves chart reviews, data reporting, and presenting findings to leadership, with a focus on continuous

Qualifications

• Responsible for ensuring accuracy, quality, and completeness of clinical documentation to support patient care, regulatory compliance, and appropriate reimbursement.
• Collaborates with providers, coders, case managers, and the healthcare team to validate severity of illness, risk of mortality, and medical necessity.
• Conducts comprehensive chart reviews and clarifies provider documentation to improve clinical accuracy and data integrity.
• Coordinates reporting, trending, and analysis to support organizational quality initiatives and documentation integrity goals.

Responsibilities

• Performs admission and continued stay reviews to validate principal diagnosis, comorbidities, and clinical indicators supporting severity of illness.
• Conducts follow-up reviews to confirm provider responses and integration of documentation into the medical record.
• Partners with coding specialists to resolve documentation and data discrepancies that impact coding accuracy and reimbursement.
• Develops and maintains data reports, spreadsheets, and dashboards to track trends and outcomes related to documentation integrity.
• Prepares summaries and presentations of review findings and documentation performance for leadership and hospital committees.
• Supports continuous improvement initiatives by identifying gaps in documentation and recommending process enhancements.
• Maintains current knowledge of coding, CDI practices, and regulatory changes to guide accurate documentation review.
• Performs other duties as assigned.

Education

Associate’s degree

Job description

University of Kentucky is seeking an Inpatient Clinical Documentation Specialist II to ensure accuracy, quality, and completeness of clinical documentation for patient care, regulatory compliance, and reimbursement. You will collaborate with providers, coders, case managers, and the healthcare team to validate severity of illness, risk of mortality, and medical necessity.

The role involves chart reviews, data reporting, and presenting findings to leadership, with a focus on continuous